Hodgkin's disease is one of a group of cancers called lymphomas. Lymphoma is a general term for cancers that develop in the lymphatic system. Hodgkin's disease, an uncommon lymphoma, accounts for less than 1 percent of all cases of cancer in this country. Other cancers of the lymphatic system are called non-Hodgkin's lymphomas. Non-Hodgkin's lymphomas are the subject of another NCI booklet, What You Need To Know About(tm) Non-Hodgkin's Lymphoma.

Lymphatic system
The lymphatic system is part of the body's immune system. It helps the body fight disease and infection. The lymphatic system includes a network of thin lymphatic vessels that branch, like blood vessels, into tissues throughout the body. Lymphatic vessels carry lymph, a colorless, watery fluid that contains infection-fighting cells called lymphocytes. Along this network of vessels are small organs called lymph nodes. Clusters of lymph nodes are found in the underarms, groin, neck, chest, and abdomen. Other parts of the lymphatic system are the spleen, thymus, tonsils, and bone marrow. Lymphatic tissue is also found in other parts of the body, including the stomach, intestines, and skin.

Cancer is a group of many related diseases that begin in cells, the body's basic unit of life. To understand Hodgkin's disease, it is helpful to know about normal cells and what happens when they become cancerous. The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed, creating a mass of extra tissue. This mass is called a growth or tumor. Tumors can be either benign (not cancerous) or malignant (cancerous).

In Hodgkin's disease, cells in the lymphatic system become abnormal. They divide too rapidly and grow without any order or control. Because lymphatic tissue is present in many parts of the body, Hodgkin's disease can start almost anywhere. Hodgkin's disease may occur in a single lymph node, a group of lymph nodes, or, sometimes, in other parts of the lymphatic system such as the bone marrow and spleen. This type of cancer tends to spread in a fairly orderly way from one group of lymph nodes to the next group. For example, Hodgkin's disease that arises in the lymph nodes in the neck spreads first to the nodes above the collarbones, and then to the lymph nodes under the arms and within the chest. Eventually, it can spread to almost any other part of the body.

Risk Factors Associated with Hodgkin's Disease
Scientists at hospitals and medical centers all across the country are studying Hodgkin's disease. They are trying to learn more about what causes the disease and more effective methods of treatment.

At this time, the cause or causes of Hodgkin's disease are not known, and doctors can seldom explain why one person gets this disease and another does not. It is clear, however, that Hodgkin's disease is not caused by an injury, and it is not contagious; no one can "catch" this disease from another person.

By studying patterns of cancer in the population, researchers have found certain risk factors that are more common in people who get Hodgkin's disease than in those who do not. However, most people with these risk factors do not get Hodgkin's disease, and many who do get this disease have none of the known risk factors.

The following are some of the risk factors associated with this disease:

Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more common in men than in women.

Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing this disease.

Viruses -- Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's disease.

People who are concerned about the chance of developing Hodgkin's disease should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's age, medical history, and other factors.

Symptoms

A painless swelling in the lymph nodes in the neck, underarm, or groin

Unexplained recurrent fevers

Night sweats

Unexplained weight loss

Itchy skin

When symptoms like these occur, they are not sure signs of Hodgkin's disease. In most cases, they are actually caused by other, less serious conditions, such as the flu. When symptoms like these persist, however, it is important to see a doctor so that any illness can be diagnosed and treated. Only a doctor can make a diagnosis of Hodgkin's disease. Do not wait to feel pain; early Hodgkin's disease may not cause pain.

Diagnosis and Staging
If Hodgkin's disease is suspected, the doctor asks about the person's medical history and performs a physical exam to check general signs of health. The exam includes feeling to see if the lymph nodes in the neck, underarm, or groin are enlarged. The doctor may order blood tests.

The doctor may also order tests that produce pictures of the inside of the body. These may include:

X-rays: High-energy radiation used to take pictures of areas inside the body, such as the chest, bones, liver, and spleen.

CT (or CAT) scan: A series of detailed pictures of areas inside the body. The pictures are created by a computer linked to an x-ray machine.

MRI (magnetic resonance imaging): Detailed pictures of areas inside the body produced with a powerful magnet linked to a computer.

The diagnosis depends on a biopsy. A surgeon removes a sample of lymphatic tissue (part or all of a lymph node) so that a pathologist can examine it under a microscope to check for cancer cells. Other tissues may be sampled as well. The pathologist studies the tissue and checks for Reed-Sternberg cells, large abnormal cells that are usually found with Hodgkin's disease.

A patient who needs a biopsy may want to ask the doctor some of the following questions:

Why do I need to have a biopsy?

How long will the biopsy take? Will it hurt?

How soon will I know the results?

If I do have cancer, who will talk with me about treatment? When?

If the biopsy reveals Hodgkin's disease, the doctor needs to learn the stage, or extent, of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Treatment decisions depend on these findings.

The doctor considers the following to determine the stage of Hodgkin's disease:

The number and location of affected lymph nodes;

Whether the affected lymph nodes are on one or both sides of the diaphragm (the thin muscle under the lungs and heart that separates the chest from the abdomen); and

Whether the disease has spread to the bone marrow, spleen, or places outside the lymphatic system, such as the liver.

In staging, the doctor may use some of the same tests used for the diagnosis of Hodgkin's disease. Other staging procedures may include additional biopsies of lymph nodes, the liver, bone marrow, or other tissue. A bone marrow biopsy involves removing a sample of bone marrow through a needle inserted into the hip or another large bone. Rarely, an operation called a laparotomy may be performed. During this operation, a surgeon makes an incision through the wall of the abdomen and removes samples of tissue. A pathologist examines tissue samples under a microscope to check for cancer cells.

Treatment
The doctor develops a treatment plan to fit each patient's needs. Treatment for Hodgkin's disease depends on the stage of the disease, the size of the enlarged lymph nodes, which symptoms are present, the age and general health of the patient, and other factors. (Treatment for children with Hodgkin's disease is not discussed here. The Cancer Information Service and the other resources listed under "National Cancer Institute Information Resources" can provide up-to-date information about Hodgkin's disease in children).

Patients with Hodgkin's disease may be vaccinated against the flu, pneumonia, and meningitis. They should discuss a vaccination plan with their health care provider.

Hodgkin's disease is often treated by a team of specialists that may include a medical oncologist, oncology nurse, and/or radiation oncologist. Hodgkin's disease is usually treated with radiation therapy or chemotherapy. The doctors may decide to use one treatment method or a combination of methods.

Taking part in a clinical trial (research study) to evaluate promising new ways to treat Hodgkin's disease is an important option for many people with this disease. For more information, see the "Clinical Trials" section.

Getting a Second Opinion
Before starting treatment, patients may want a second opinion to confirm their diagnosis and treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor who can give a second opinion:

The patient's doctor may be able to suggest specialists to consult.

The Cancer Information Service, at 1-800-4-CANCER, can tell callers about cancer treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.

Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.

The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and medical background. This resource, produced by the American Board of Medical Specialties, is available in most public libraries and on the Internet.

Preparing for Treatment
Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for people to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

These are some questions a patient may want to ask the doctor before treatment begins:

What is my exact diagnosis?

What is the stage of the disease?

What are my treatment choices? Which do you recommend for me? Why?

What are the risks and possible side effects of each treatment?

What side effects should I report to you?

How long will treatment last?

What are the chances that the treatment will be successful?

Will treatment affect my normal activities? If so, for how long?

Are new treatments under study? Would a clinical trial be appropriate for me?

What is the treatment likely to cost.

Patients do not need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

Methods of Treatment
Radiation therapy and chemotherapy are the most common treatments for Hodgkin's disease, although bone marrow transplantation, peripheral stem cell transplantation, and biological therapies are being studied in clinical trials.

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. Depending on the stage of the disease, treatment with radiation may be given alone or with chemotherapy. Radiation therapy is local therapy; it affects cancer cells only in the treated area. Radiation treatment for Hodgkin's disease usually involves external radiation, which comes from a machine that aims the rays at a specific area of the body. External radiation does not cause the body to become radioactive. Most often, treatment is given on an outpatient basis in a hospital or clinic.

These are some questions a patient may want to ask the doctor before having radiation therapy:

What is the goal of this treatment?

What are its risks and possible side effects?

What side effects should I report to you?

How will the radiation be given?

When will the treatments begin? When will they end?

How will I feel during therapy?

What can I do to take care of myself during therapy?

How will we know if the radiation therapy is working?

How will treatment affect my normal activities?

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for Hodgkin's disease usually consists of a combination of several drugs. It may be given alone or followed by radiation therapy.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most anticancer drugs are given by injection into a blood vessel (IV); some are given by mouth. Chemotherapy is a systemic therapy, meaning that the drugs enter the bloodstream and travel throughout the body.

Usually, a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

These are some questions patients may want to ask the doctor before starting chemotherapy:

What is the goal of this treatment?

What drugs will I be taking?

Will the drugs cause side effects? What can I do about them?

What side effects should I report to you?

How long will I need to take this treatment?

What can I do to take care of myself during treatment?

How will we know if the drugs are working?

Clinical Trials
Many people with Hodgkin's disease take part in clinical trials. Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. Trials are exploring new ways of giving radiation therapy and chemotherapy, new drugs and new drug combinations, and biological therapies. High-dose chemotherapy with bone marrow or peripheral blood stem cell transplantation is also being evaluated. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard treatment to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of Hodgkin's disease. Each achievement brings researchers closer to the eventual control of cancer.

People who take part in clinical trials have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science.

Patients who are interested in entering a clinical trial should talk with their doctor. They may also want to read the National Cancer Institute booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know, which describes how studies are carried out and explains their possible benefits and risks. The NCI Web site at http://cancer.gov provides detailed information about ongoing studies for Hodgkin's disease. Another way to learn about clinical trials is through the Cancer Information Service.

Side Effects of Treatment
Treatments for Hodgkin's disease are very powerful. It is hard to limit the effects of therapy so that only cancer cells are destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend mainly on the type and extent of the therapy. Side effects may not be the same for everyone, and they may even change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment. They can also lessen or control many of the side effects that may occur during and after treatment.

Side Effects of Radiation Therapy
The side effects of radiation depend on the treatment dose and the part of the body that is treated. During radiation therapy, people are likely to become extremely tired, especially in the later weeks of treatment. Rest is important, but doctors usually advise patients to try to stay as active as they can.

It is common to lose hair in the treated area and for the skin to become red, dry, tender, and itchy. There may also be permanent darkening or "bronzing" of the skin in the treated area.

When the chest and neck are treated, patients may have a dry, sore throat and some trouble swallowing. Sometimes, they have shortness of breath or a dry cough. Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Often, changes in diet or medicine can ease these problems.

Radiation therapy also may cause a decrease in the number of white blood cells, cells that help protect the body against infection, or platelets, cells that help the blood to clot. If that happens, patients need to be careful to avoid possible sources of infection or injury. The doctor monitors a patient's blood count very carefully during radiation treatment. If necessary, treatment may have to be postponed to let the blood counts return to normal.

Although the side effects of radiation therapy can be difficult, they can usually be treated or controlled. It may also help to know that, in most cases, side effects are not permanent. However, patients may want to discuss with their doctor the possible long-term effects of radiation treatment on fertility (the ability to produce children) and the increased chance of second cancers after treatment is over. (The "Followup Care" section includes more information about the chance for second cancers.) Loss of fertility may be temporary or permanent, depending on if the testes or ovaries received radiation and the patient's age. For men, sperm banking before treatment may be a choice. Women's menstrual periods may stop, and they may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women.

Side Effects of Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the doses the patient receives. As with other types of treatment, side effects may vary from person to person.

Anticancer drugs generally affect cells that divide rapidly. In addition to cancer cells, these include blood cells, which fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected, the patient is more likely to get infections, may bruise or bleed easily, and may feel unusually weak and tired.

Cells in hair roots also divide rapidly; therefore, chemotherapy may lead to hair loss. Hair loss is a major concern for many patients. Some anticancer drugs only cause the hair to thin out, while others may result in the loss of all body hair. People may cope with hair loss better if they decide how to handle hair loss before starting treatment.

Cells that line the digestive tract also divide rapidly, and are often damaged by chemotherapy. As a result, side effects may include poor appetite, nausea and vomiting, and/or mouth and lip sores.

Most side effects go away gradually during the recovery periods between treatments or after treatment is over. Sometimes, however, chemotherapy results in a permanent loss of fertility. The National Cancer Institute booklet Chemotherapy and You has helpful information about chemotherapy and coping with side effects.

Nutrition During Cancer Treatment
Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and regain strength. Good nutrition often helps people feel better and have more energy.

Some people with cancer find it hard to eat a balanced diet because they may lose their appetite. In addition, common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods taste different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.

Doctors, nurses, and dietitians can offer advice on how to get enough calories and protein during cancer treatment. Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

Recovery and Outlook
It is natural for anyone facing cancer to be concerned about what the future holds. Understanding the nature of cancer and what to expect can help patients and their loved ones plan treatment, anticipate lifestyle changes, and make quality of life and financial decisions.

Cancer patients frequently ask their doctors or search on their own for statistics to answer the question, "What is my prognosis?" Prognosis is a prediction of the future course and outcome of a disease and an indication of the likelihood of recovery from that disease. However, it is only an estimate. When doctors discuss a patient's prognosis, they are attempting to project what is likely to occur for that individual patient. The prognosis for Hodgkin's disease can be affected by many factors, particularly the stage of the cancer, the patient's response to treatment, and the patient's age and general health.

Sometimes people use statistics to try to figure out their chances of being cured. However, statistics reflect the experience of a large group of patients. They cannot be used to predict what will happen to a particular patient because no two patients are alike; treatment and responses vary greatly. The doctor who is most familiar with a patient's situation is in the best position to help interpret statistics and discuss the patient's prognosis.

When doctors talk about surviving cancer, they may use the term remission rather than cure. Although many people with Hodgkin's disease are successfully treated, doctors use the term remission because cancer can return. It is important to discuss the possibility of recurrence with the doctor.

Followup Care
People who have had Hodgkin's disease should have regular followup examinations after their treatment is over and for the rest of their lives. Followup care is an important part of the overall treatment process, and people who have had cancer should not hesitate to discuss it with their health care provider. Patients treated for Hodgkin's disease have an increased chance of developing leukemia; non-Hodgkin's lymphoma; and cancers of the colon, lung, bone, thyroid, and breast. Regular followup care ensures that patients are carefully monitored, any changes in health are discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between followup appointments, people who have had Hodgkin's disease should report any health problems as soon as they appear.

Support for People with Cancer
Living with a serious disease is not easy. People with cancer and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services. Several useful booklets, including Taking Time, are available from the Cancer Information Service and through other sources listed in the "National Cancer Institute Information Resources" section.

Friends and relatives can be very supportive. Also, it helps many patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each person is different. Treatments and ways of dealing with cancer that work for one person may not be right for another -- even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the health care provider.

People living with cancer may worry about what the future holds. They may worry about holding their jobs, caring for their families, personal relationships, or continuing with daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, psychologist, or member of the clergy can be helpful to people who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest groups that can help with rehabilitation, emotional support, financial aid, transportation, or home care.

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